All right, my name is Yoshimita Rai. I'm the founder of ECCP. This Emergency Crew Care Program is the official name of Stanford Hospital. It's an ED-based crew care consultation management model, and I'm going to explain what that means. I have no disclosures. To explain what the ECCP looks like, it's probably good to compare the baseline workflow before the ECCP existed and what happens afterwards. So a critical ill patient comes to your emergency department and the ED team sees the patients, and after their initial resuscitation, if they feel like they need a medical ICU consultation and admissions, they're called MICU triage fellow. And then after triage fellow sees the patients, they discuss the assessment plan and disposition with the MICU attending on call. That person may or may not see the patient depending on the day. They're not here over the nighttime. And so basically the traditional dispositions of MICU, yes or no, will be provided. We at Stanford Hospital have this luxury of having not just the primary ED nurse who may or may not be trained in critical care, we have this ECC nurse who is dual trained in emergency medicine and critical care. So there's one ECC nurse 24-7 supervising primary ED nurse. So that's the baseline, okay? This is the baseline. Now with the ECCP, we still have the same luxury of nursing support. And by the way, this is California, so two-to-one nursing ratio once critical care admission orders gets into the patients in ED. We have same ED resuscitation at the beginning. We don't take over those care. And then once the ED team is ready to consult MICU, instead of calling triage fellow, they call the ECC attending instead. And our priority is to take care of these ED patients, so we see them right away. And we're gonna be given not only those traditional two disposition, yes or no, we have a third disposition which is admitting to ourselves. ECC service admissions. For those patients that we think we can downgrade them within six hours, so the borderline patients or patients who are DKA, then you know you can downgrade them. Even if there's a bed open in ICU, we keep them on purpose for those patients because we know we can save those bed for the patient who really needs it later on. And by the way, we take care of the patients upstairs as well, even though our priority is the ED patients, but all these evening admissions to the ICU coming from OR, transfer from outside hospital, floor decompensation, we take care of them as well. And then even though it looks like the ECC is doing everything here, we collaborate, it works very closely with the medical ICU team as well and supervise their procedures and so forth. So the key features of ECCP, basically this ECC attending who are dual training critical care and emergency medicine provides the MICU consultation, triage, resuscitation, supervise the procedures, have comprehensive goals of care discussions, they optimize the ICU bed idealizations through early downgrade, that's what we do. And it's a less resource intensive model because you don't really pay penny for the system other than just hiring ECC attending who generates more than the cost of hiring us anyway. And that's because of no need for a dedicated physical space, right? We're taking advantage of pre-existing ED resources, the pharmacists, respiratory therapists, nurses, they're already there anyway. And then we have staffing only during peak hours model, so Monday through Friday, 2 p.m. to midnight. Why, why not 24 seven, right, you think about? Well, this is the thing, the distribution of the MICU patients coming through the ED door is not universal and also we don't have the volume to justify doing this 24 seven. So, but when we have this two to midnight model, not only that you take care of these patients in the pink box, but you also take care of a decent amount of patients in the green box because there's a time lag between ED arrival and when the ED team is ready to contact the MICU team for consultation. It's pretty efficient system actually. And what about the data? Okay, that sounds good in theory, but what about the data? Well, here's the data. We published this last June of 2013, I'm sorry, 2023. We did a difference in difference analysis. We didn't do pre versus post. The problem with that is that you can have all this confounding, right? Maybe you just do a better job as institutions or ARDS protocols or sepsis protocol. What we did is we took advantage of the fact that we have this time that we're not there, right, during intervention hours outside of two to midnight, Monday through Friday, we're not there. So you can use that as additional group to compare the data. So you basically look at the outcomes for D minus C during the hours of ECG vibrations and then B minus A, and you basically compare between two. So that's called difference in difference analysis to be more robust study design. And then what we found, primary outcome number one, mortality, so we had 2,250 patients in the study. Risk adjusted in-hospital mortality went down by 6%, which corresponds to relative risk reduction of 28.3%, and that means that number needed to treat is 17 patients to prevent one in-hospital death. It turns out to be that this mortality benefits not across the whole patients. When you divide it into three different severe illness group, we're not really affecting the mortality for the least sickest patient group at the bottom, like a DKA patients, or the top one who might have multiple organ failure by the time we get involved. Those are not the one, it's the middle group that's actually, we're making this impact in mortality. Home of primary outcome number two is ED downgrade less than six hours. Remember, we're trying to optimize the IC resources, right? So if you can downgrade them while they're still in ED, less than six hours, hey, you're saving ICU beds. So it basically went up by 4.8%, but as you can see, it's not technically statistically significant. We did see a statistically significant increase of 8.8% among the intermediate severe illness group. Other key findings of the studies, so there's no change in ED length of stay. Remember, we're keeping some of the ED patients on purpose, even if there's a bed and upstairs. So you would think, whoa, maybe ED length of stay goes up. It didn't. Well, we're saving lives, so you must be keeping those patients longer in hospital because they're sick patients, right? It turned out that hospital length of stay did not go up either. And then what about the bounce up, right? Even if you're downgrading these patients left and right, well, if they're going to upstairs to ICU later on within 24 hours, that's not good. That's not safe, or it turns out to be that's not what's happening. It's a safe downgrade. So what is the take-home message? It's an ED-based crew care consultation management model. It's a less resource-intensive model, no dedicated physical space. We're like a white blood cell. We go to wherever the patients are. So they come into the initial ED room. They don't move. They just stay there. We come to their bedside. Peak hour staffing, and we save lives. Well, it's associated with saving lives in ICU beds, and biggest impact is seen in intermediate severe illness group. Thank you very much.

Emergency Crew Care Program

critical care

ICU resource optimization

in-hospital mortality reduction

difference-in-difference analysis